Board Hearings are conducted in English. If you need a tanslator, select Yes and indicate the language needed.

Enter the name, address, phone number and other information of the employer you were working for at the time of the injury/illness.

Your employer is the company or agency that issues your paycheck. If you are a contractor at a work site or office, the staffing agency or vendor who hired you is your employer, not the work site or office where you report to work.

Regular Duty Limited Duty

Same Employer New Employer Self Employed

Yes No

Yes No

Off-Site Treatment

Where was your first Off-Site medical treatment?

Emergency Room Doctor's Office Clinic/Hospital/Urgent Care Hospital Stay over 24 hours

Name

Phone

Address 1

Address 2

City

State

Zip

Yes No

Doctor treating you

Name

Phone

Address 1

Address 2

City

State

Zip

Yes No

Previous Injury/Illness

Were you treated by a Doctor?

Yes No

Name

Phone

Address 1

Address2

City

State

Zip

Was the previous injury/illness work related?

Yes No

Were you working for the same employer that you work for now?

Yes No